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Sclerotherapy for esophageal varices

Definition

Sclerotherapy for esophageal varices, also called endoscopic
sclerotherapy, is a treatment for esophageal bleeding that involves the
use of an endoscope and the injection of a sclerosing solution into veins.

Purpose

Esophageal varices are enlarged or swollen veins on the lining of the
esophagus which are prone to bleeding. They are life-threatening and can
be fatal in up to 50% of patients. Esophageal varices are a complication
of portal hypertension, a condition characterized by increased blood
pressure in the portal vein resulting from such liver disease, as liver
cirrhosis. Increased pressure causes the veins to balloon outward. The
vessels may rupture, causing vomiting of blood and bloody stools.

In most hospitals, sclerotherapy for esophageal varices is the treatment
of choice to stop esophageal bleeding during acute episodes, and to
prevent further incidences of bleeding. Emergency sclerotherapy is often
followed by preventive treatments to eradicate distended esophageal veins.

Demographics

Bleeding esophageal varices are a serious complication of liver disease.
In the United States, at least 50% of people who survive bleeding
esophageal varices are at risk of recurrent bleeding during the next one
to two years.

Description

Sclerotherapy for esophageal varices involves injecting a strong and
irritating solution (a sclerosant) into the veins and/or the area beside
the distended vein. Sclerosant injected directly into the vein causes
blood clots to form and stops the bleeding, while sclerosant injected into
the area beside the distended vein stops the bleeding by thickening and
swelling the vein to compress the blood vessel. Most physicians inject the
sclerosant directly into the vein, although injections into the vein and
the surrounding area are both effective. Once bleeding has been stopped,
the treatment can be used to significantly reduce or destroy the varices.

Sclerotherapy for esophageal varices is performed with the patient awake
but sedated. Hyoscine butylbromide (Buscopan) may be administered to
freeze the esophagus, making injection of the sclerosant easier. During
the procedure, an endoscope is passed through the patient's mouth
to the esophagus to allow the surgeon to view the inside. The branches of
the blood vessels at or
just above where the stomach and esophagus come together, the usual site
of variceal bleeding, are located. After the bleeding vein is identified,
a long, flexible sclerotherapy needle is passed through the endoscope.
When the tip of the needle's sheath is in place, the needle is
advanced, and the sclerosant is injected into the vein or the surrounding
area. The most commonly used sclerosants are ethanolamine and sodium
tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as
many times as necessary to eradicate all distended veins.

Diagnosis/Preparation

A radiologist assesses patients for sclerotherapy based on blood work and
liver imaging studies performed using
CT scans
, ultrasound or MRI scans, and in consultation with the treating
gastroenterologist, hepatologist, or surgeon. Tests to localize bleeding
and detect active bleeding are also performed.

Before a sclerotherapy procedure, the patient's
vital signs
and other pertinent data are recorded, an intravenous line is inserted to
administer fluid or blood, and a sedative is prescribed.

Aftercare

After sclerotherapy for esophageal varices, the patient will be observed
for signs of blood loss, lung complications, fever, a perforated
esophagus, or other complications. Vital signs are monitored, and the
intravenous line maintained. Pain medication is usually prescribed. After
leaving the hospital, the patient follows a diet prescribed by the
physician, and, if appropriate, can take mild pain relievers.

Risks

Risks associated with sclerotherapy include complications that can arise
from use of the sclerosant or from the endoscopic procedure. Minor
complications, which cause discomfort but do not require active treatment
or prolonged hospitalization, include transient chest pain, difficulty
swallowing, and fever, which usually go away after a few days. Some
patients may have allergic reactions to the sclerosant solution. Infection
occurs in up to 50% of cases. In 2-10% of patients, the esophagus
tightens, but this complication can usually be treated with dilatation.
More serious complications may occur in 10-15% of patients. These include
perforation or bleeding of the esophaggus and lung problems, such as
aspiration pneumonia. Long-term sclerotherapy can also damage the
esophagus and increase the patient's risk of developing cancer.

Patients with advanced liver disease complicated by bleeding are very poor
risks for this procedure. The surgery, premedications, and anesthesia may
be sufficient to tip the patient into protein intoxication and hepatic
coma. The blood in the bowels acts like a high protein meal and may induce
protein intoxication.

Normal results

Normal sclerotherapy results include the control of acute bleeding if
present and the shrinking of the esophageal varices.

Morbidity and mortality rates

Sclerotherapy for esophageal varices has a 20-40% incidence of
complications and a 1–2% mortality rate. The procedure controls
acute bleeding in about 90% of patients, but it may have to be repeated
within the first 48 hours to achieve this success rate. During the initial
hospitalization, sclerotherapy is usually performed two or three times.
Preventive treatments are scheduled every few weeks or so, depending on
the patient's risk level and healing rate. Several studies have
shown that the risk of recurrent bleeding is much lower in patients
treated with sclerotherapy: 30-50% as opposed to 70–80% for
patients not treated with sclerotherapy.

Alternatives

Pharmacological agents are also used in the treatment of esophageal
varices. Such drugs as vasopressin and somatostatin are administered to
actively bleeding patients on admission, while propranolol, nadolol or
subcutaneous octreotide are used to prevent subsequent bleeding after
successful endoscopic variceal eradication. Vasopressin or vasopressin
with nitroglycerin has been proven effective in the acute control of
variceal hemorrhage. Somatostatin is more effective in the control of
active bleeding when compared to vasopressin, glypressin, endoscopic
sclerotherapy or balloon tamponade.
Octreotide has comparable outcomes to vasopressin, terlipressin or
endoscopic sclerotherapy.
Liver transplantation
should be considered as an alternative for patients with bleeding varices
from liver disease.

Another alternative treatment is provided by Transjugular intrahepatic
portal-systemic shunting (TIPS). In TIPS, a catheter fitted with a stent,
a wire mesh tube used to prop open a vein or artery, is inserted through a
vein in the neck into the liver. Under x ray guidance, the stent is placed
in an optimal position within the liver so as to allow blood to flow more
easily through the portal vein. This treatment reduces the excess pressure
in the esophageal varices, and thus decreases the risk of recurrent
bleeding.

User Contributions:

JUST NEED TO KNOW HOW OFTEN SHOULD YOU GET AN ENDOSCOPIC TO DETERMINE IF THERE ARE VARICES.MY HUSBAND SUFFERS FROM CIRRHOSIS AND ONLY HAD ON DONE NO VARICES WERE FOUND YET, BUT DO YOU WAIT
FOR THE RUPTURE TO OCCUR BESIDES DEVELOPING THE BLEEDING ETC.hOW OFTEN SHOULD YOU GET AN
ENDOSCOPY BEFORE THE RUPTURE OCCURS.

THANK YOU.

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